不同BavenoⅦ标准筛查进展期慢性肝病出现高风险食管胃静脉曲张的价值分析

Value of different BavenoⅦ-based criteria in screening for high-risk esophageal and gastric varices in advanced chronic liver disease

目的评价BavenoⅦ标准用于筛查国内进展期慢性肝病患者出现高风险食管胃静脉曲张(HRV)的价值,并比较与Expanded BavenoⅦ标准的优劣。方法纳入2016年1月—2018年12月期间首都医科大学附属北京世纪坛医院收治的进展期慢性肝病患者146例,根据胃镜检查是否存在HRV分为HRV组(n=68)和对照组(n=78)。分析患者的临床资料、肝脏硬度值(LSM)和胃镜结果,评价不同的BavenoⅦ标准对于诊断HRV的敏感度和特异度。计量资料组间比较采用Mann-Whitney U检验和McNemar检验;计数资料组间比较采用χ^(2)检验。对预测HRV的各变量进行单因素Logistic回归分析,对单因素分析P<0.1的变量进行多因素分析。比较两种BavenoⅦ标准诊断HRV的敏感度和特异度。结果入组患者中位年龄54(29~84)岁,男性占比65.8%,主要病因为HBV(n=115,78.8%)。Logistic单因素回归分析显示,LSM、PLT计数与HRV有关(P值均<0.05);多因素分析显示,根据BavenoⅦ标准,LSM>20 kPa或PLT<150×10^(9)/L与HRV有关(P值均<0.05);根据Expanded BavenoⅦ标准,LSM>25 kPa或PLT<110×10^(9)/L与HRV有关(P值均<0.05)。LSM和PLT诊断HRV的受试者工作特征曲线下面积分别为0.797(95%CI:0.723~0.859)和0.789(95%CI:0.714~0.852)。符合与不符合BavenoⅦ标准患者的食管胃静脉曲张和HRV患病率比较差异有统计学意义(χ^(2)值分别为23.14、23.14,P值均<0.001)。符合与不符合Expanded BavenoⅦ标准患者的食管胃静脉曲张和HRV患病率比较差异均有统计学意义(χ^(2)值分别为43.51、25.71,P值均<0.001)。虽然Expanded BavenoⅦ标准可以豁免更多的胃镜检查(32.9%vs 13.7%),但BavenoⅦ标准敏感度更高(0.98 vs 0.88),NPV更高(0.95 vs 0.83),且可更好地避免漏诊HRV(1.0%vs 9.3%)。结论BavenoⅦ标准更适用于筛查国内进展期肝病患者出现HRV。

Objective To investigate the value of BavenoⅦcriteria versus Expanded BavenoⅦcriteria in screening for high-risk varices(HRV)in patients with compensated advanced chronic liver disease(cACLD).Methods A total of 146 patients with cACLD who were admitted to Beijing Shijitan Hospital,Capital Medical University,from January 2016 to December 2018 were enrolled,and according to the absence or presence of HRV based on gastroscopy,they were divided into HRV group with 68 patients and control group with 78 patients.Clinical data,liver stiffness measurement(LSM),and gastroscopy findings were analyzed,and different BavenoⅦcriteria were analyzed in terms of their sensitivity and specificity in the diagnosis of HRV.The Mann-Whitney U test and the McNemar test were used for comparison of continuous data between groups,and the chi-square test was used for comparison of categorical data between groups.A univariate logistic regression analysis was performed for the variables used to predict HRV,and a multivariate analysis was performed for the variables with P<0.1.The two sets of BavenoⅦcriteria were compared in terms of their sensitivity and specificity in the diagnosis of HRV.Results A total of 146 patients were enrolled in the study,among whom 68(46.6%)were found to have HRV.The median age was 54 years(range 29-84 years),male patients accounted for 65.8%,and hepatitis B virus was the main etiology observed in 115 patients(78.8%).The univariate logistic regression analysis showed that LSM and platelet count(PLT)were associated with HRV(both P<0.05).The multivariate analysis showed that based on BavenoⅦcriteria,LSM>20 kPa or PLT<150×10^(9)/L was associated with HRV(both P<0.05),and based on Expanded BavenoⅦcriteria,LSM>25 kPa or PLT<110×10^(9)/L was associated with HRV(both P<0.05).LSM and PLT had an area under the ROC curve of 0.797(95%confidence interval[CI]:0.723-0.859)and 0.789(95%CI:0.714-0.852),respectively,in the diagnosis of HRV.There were significant differences in the prevalence rates of esophageal and gastric varices and HRV between the patients who met BavenoⅦcriteria and those who did not meet such criteria(χ^(2)=23.14 and 23.14,both P<0.001),as well as between the patients who met Expanded BavenoⅦcriteria and those who did not meet such criteria(χ^(2)=43.51 and 25.71,both P<0.001).Although a higher proportion of patients were exempted from gastroscopy based on Expanded BavenoⅦcriteria(32.9%vs 13.7%),BavenoⅦcriteria had higher sensitivity(0.98 vs 0.88)and negative predictive value(0.95 vs 0.83)and could better avoid the missed diagnosis of HRV(1.0%vs 9.3%).Conclusion BavenoⅦcriteria are more suitable for the screening for HRV in cACLD patients in China.